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Sinusitis

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Sinusitis

Diagnostic tests are not routinely recommended; no diagnostic tests can adequately differentiate between viral and bacterial rhinosinusitis (2)[C].

Sinus CT if signs suggest extrasinus involvement or to evaluate chronic rhinosinusitis

Most cases resolve with supportive care (treating pain, nasal symptoms). Antibiotics should be reserved for symptoms that persist >10 days, onset with severe symptoms (high fever, purulent nasal discharge, facial pain) for at least 3 to 4 consecutive days, or worsening signs/symptoms that were initially improving (1,2)[C].

Return if no improvement after 72 hours or no resolution of symptoms after 10 days of antibiotics.

Alleviation of symptoms within 72 hours with complete resolution within 10 to 14 days

11 Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112.22 Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-S39.33 Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, et al. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014;(2):CD000243.44 Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.55 Olarte L, Hulten KG, Lamberth L, et al. Impact of the 13-valent pneumococcal conjugate vaccine on chronic sinusitis associated with Streptococcus pneumoniae in children. Pediatr Infect Dis J. 2014;33(10):1033-1036.66 Hayward G, Heneghan C, Perera R, et al. Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis. Ann Fam Med. 2012;10(3):241-249.

  • Sinuses are not fully developed until age 20 years. Maxillary and ethmoid sinuses, although small, are present from birth.
  • Because children have an average of six to eight colds per year, they are at risk for developing sinusitis.
  • Diagnosis can be more difficult than in adults because symptoms are often more subtle.

Sinuses are not fully developed until age 20 years. Maxillary and ethmoid sinuses, although small, are present from birth.

Because children have an average of six to eight colds per year, they are at risk for developing sinusitis.

Diagnosis can be more difficult than in adults because symptoms are often more subtle.

DIFFERENTIAL DIAGNOSIS

  • Dental disease
  • CF
  • Wegener granulomatosis
  • HIV infection
  • Kartagener syndrome
  • Neoplasm
  • Headache, tension, or migraine

DIAGNOSTIC TESTS & INTERPRETATION

  • None indicated in routine evaluation
  • Routine use of sinus radiography discouraged because of the following:≥3 clinical findings have similar diagnostic accuracy as imaging.Imaging does not distinguish viral from bacterial etiology.
  • Limited coronal CT scan can be useful in recurrent infection or failure to respond to medical therapy.
  • ≥3 clinical findings have similar diagnostic accuracy as imaging.
  • Imaging does not distinguish viral from bacterial etiology.
  • Inflammation, edema, thickened mucosa
  • Impaired ciliary function
  • Metaplasia of ciliated columnar cells
  • Relative acidosis and hypoxia within sinuses
  • Polyps

TREATMENT

GENERAL MEASURES

  • Hydration
  • Steam inhalation 20 to 30 minutes TID
  • Saline irrigation (Neti pot) or nose drops
  • Sleep with head of bed elevated.
  • Avoid exposure to cigarette smoke or fumes.
  • Avoid caffeine and alcohol.
  • Antibiotics are indicated only when findings suggest bacterial infection.
  • Analgesics, NSAIDs
  • Acute viral sinusitis is self-limiting; antibiotics should not be used.

MEDICATION

  • DecongestantsPseudoephedrine HClPhenylephrine nasal spray (limited use)Oxymetazoline nasal spray (e.g., Afrin) (not to be used >3 days)
  • AnalgesicsAcetaminophenAspirinNSAIDs
  • AntibioticsAntibiotics have a slight advantage over placebo at 7 to 14 days (3)[A], yet most improve without therapy.Reserve antibiotic use for patients with moderate to severe disease.Choice should be based on understanding of antibiotic resistance in the community.Infectious Disease Society of America recommends the following (1)[C]:Start antibiotics as soon as clinical diagnosis of acute bacterial sinusitis is made.Use amoxicillin-clavulanate rather than amoxicillin alone.Amoxicillin-clavulanate 875/125 mg q12h; 2 g orally BID in geographic regions with high rates of resistant S. pneumoniaeDoxycycline: 100 mg PO BID an alternative to amoxicillin-clavulanate for initial therapy (adults only)Trimethoprim-sulfamethoxazole (TMP/SMX) and 3rd generation cephalosporins not recommended due to high rate of resistance (1)[C]Treat for 5 to 7 days in adults if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence). Treat for 10 to 14 days in children if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence).American Academy of Pediatrics recommends the following (1)[C]:Amoxicillin: 45 to 90 mg/kg/day in 2 divided doses if uncomplicated acute bacterial sinusitis in childrenAmoxicillin-clavulanate: 80 to 90 mg/6.4 mg/kg/day in 2 divided doses for children with severe illness, recent antibiotics, or attending daycareLevofloxacin: 10 to 20 mg/kg/day max 750mg/day if history of type 1 hypersensitivity to PCN (1)[C]Clindamycin (30 to 40 mg/kg/day) + cefixime (8mg/kg/day in 2 divided doses) or cefpodoxime (10 mg/kg/day in 2 divided doses) (1)[C] for non-type 1 PCN allergyCeftriaxone: 50 mg/kg IM single dose if not able to tolerate oral meds (4)[C]
  • Because allergies may be a predisposing factor, some patients may benefit from use of the following agents:Oral antihistaminesLoratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), desloratadine (Clarinex), or levocetirizine (Xyzal)Chlorpheniramine (Chlor-Trimeton)Diphenhydramine (Benadryl)Leukotriene inhibitors (Singulair, Accolate), especially in patients with asthmaNasal steroids (i.e., fluticasone [Flonase])
  • Pseudoephedrine HCl
  • Phenylephrine nasal spray (limited use)
  • Oxymetazoline nasal spray (e.g., Afrin) (not to be used >3 days)
  • Acetaminophen
  • Aspirin
  • NSAIDs
  • Antibiotics have a slight advantage over placebo at 7 to 14 days (3)[A], yet most improve without therapy.
  • Reserve antibiotic use for patients with moderate to severe disease.
  • Choice should be based on understanding of antibiotic resistance in the community.
  • Infectious Disease Society of America recommends the following (1)[C]:Start antibiotics as soon as clinical diagnosis of acute bacterial sinusitis is made.Use amoxicillin-clavulanate rather than amoxicillin alone.Amoxicillin-clavulanate 875/125 mg q12h; 2 g orally BID in geographic regions with high rates of resistant S. pneumoniaeDoxycycline: 100 mg PO BID an alternative to amoxicillin-clavulanate for initial therapy (adults only)Trimethoprim-sulfamethoxazole (TMP/SMX) and 3rd generation cephalosporins not recommended due to high rate of resistance (1)[C]Treat for 5 to 7 days in adults if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence). Treat for 10 to 14 days in children if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence).
  • American Academy of Pediatrics recommends the following (1)[C]:Amoxicillin: 45 to 90 mg/kg/day in 2 divided doses if uncomplicated acute bacterial sinusitis in childrenAmoxicillin-clavulanate: 80 to 90 mg/6.4 mg/kg/day in 2 divided doses for children with severe illness, recent antibiotics, or attending daycareLevofloxacin: 10 to 20 mg/kg/day max 750mg/day if history of type 1 hypersensitivity to PCN (1)[C]Clindamycin (30 to 40 mg/kg/day) + cefixime (8mg/kg/day in 2 divided doses) or cefpodoxime (10 mg/kg/day in 2 divided doses) (1)[C] for non-type 1 PCN allergyCeftriaxone: 50 mg/kg IM single dose if not able to tolerate oral meds (4)[C]
  • Start antibiotics as soon as clinical diagnosis of acute bacterial sinusitis is made.
  • Use amoxicillin-clavulanate rather than amoxicillin alone.
  • Amoxicillin-clavulanate 875/125 mg q12h; 2 g orally BID in geographic regions with high rates of resistant S. pneumoniae
  • Doxycycline: 100 mg PO BID an alternative to amoxicillin-clavulanate for initial therapy (adults only)
  • Trimethoprim-sulfamethoxazole (TMP/SMX) and 3rd generation cephalosporins not recommended due to high rate of resistance (1)[C]
  • Treat for 5 to 7 days in adults if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence). Treat for 10 to 14 days in children if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence).
  • Amoxicillin: 45 to 90 mg/kg/day in 2 divided doses if uncomplicated acute bacterial sinusitis in children
  • Amoxicillin-clavulanate: 80 to 90 mg/6.4 mg/kg/day in 2 divided doses for children with severe illness, recent antibiotics, or attending daycare
  • Levofloxacin: 10 to 20 mg/kg/day max 750mg/day if history of type 1 hypersensitivity to PCN (1)[C]
  • Clindamycin (30 to 40 mg/kg/day) + cefixime (8mg/kg/day in 2 divided doses) or cefpodoxime (10 mg/kg/day in 2 divided doses) (1)[C] for non-type 1 PCN allergy
  • Ceftriaxone: 50 mg/kg IM single dose if not able to tolerate oral meds (4)[C]
  • Oral antihistaminesLoratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), desloratadine (Clarinex), or levocetirizine (Xyzal)Chlorpheniramine (Chlor-Trimeton)Diphenhydramine (Benadryl)
  • Leukotriene inhibitors (Singulair, Accolate), especially in patients with asthma
  • Nasal steroids (i.e., fluticasone [Flonase])
  • Loratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), desloratadine (Clarinex), or levocetirizine (Xyzal)
  • Chlorpheniramine (Chlor-Trimeton)
  • Diphenhydramine (Benadryl)
  • Levofloxacin (Levaquin): 750 mg/day for 5 days or moxifloxacin 400 mg/day for 5 to 7 days (adults only) (1)[C]
  • If no response to first-line therapy after 72 hoursBroaden antibiotic coverage or switch to a different class, evaluate for resistant pathogens or other causes for treatment failure (i.e., noninfectious etiology) fluoroquinolones as above.
  • Note: Bacteriologic failure rates of up to 20-25% are possible with use of azithromycin and clarithromycin.
  • If lack of response to 3 weeks of antibiotics, consider the following:CT scan of sinusesEar/nose/throat (ENT) referral
  • Broaden antibiotic coverage or switch to a different class, evaluate for resistant pathogens or other causes for treatment failure (i.e., noninfectious etiology) fluoroquinolones as above.
  • CT scan of sinuses
  • Ear/nose/throat (ENT) referral

ISSUES FOR REFERRAL

  • Meta-analyses have demonstrated no benefit of newer antibiotics over amoxicillin or doxycycline.
  • Antibiotics recommendations vary with different guidelines. Patients seen by specialists are different from those in a primary care setting. Patients usually do not have complicated sinusitis in primary care setting.American Academy of Otolaryngology-Head and Neck Surgery Foundation (2)[C] recommends the following:Consider watchful waiting without antibiotics in patients with uncomplicated mild illness (mild pain and temperature <101 °F) with assurance of follow-up within 7 days.
  • PCV-13 pneumococcal vaccine can be helpful in reducing chronic sinusitis in children (5)[B].
  • Use of intranasal steroids small but significant improvement in symptoms when used alone or in combination with antibiotics (6)[A].
  • PrecautionsDecongestants can exacerbate hypertension.Intranasal decongestants should be limited to 3 days to avoid rebound nasal congestion.

Meta-analyses have demonstrated no benefit of newer antibiotics over amoxicillin or doxycycline.

Antibiotics recommendations vary with different guidelines. Patients seen by specialists are different from those in a primary care setting. Patients usually do not have complicated sinusitis in primary care setting.

  • American Academy of Otolaryngology-Head and Neck Surgery Foundation (2)[C] recommends the following:Consider watchful waiting without antibiotics in patients with uncomplicated mild illness (mild pain and temperature <101 °F) with assurance of follow-up within 7 days.

American Academy of Otolaryngology-Head and Neck Surgery Foundation (2)[C] recommends the following:

  • Consider watchful waiting without antibiotics in patients with uncomplicated mild illness (mild pain and temperature <101 °F) with assurance of follow-up within 7 days.

Consider watchful waiting without antibiotics in patients with uncomplicated mild illness (mild pain and temperature <101 °F) with assurance of follow-up within 7 days.

PCV-13 pneumococcal vaccine can be helpful in reducing chronic sinusitis in children (5)[B].

Use of intranasal steroids small but significant improvement in symptoms when used alone or in combination with antibiotics (6)[A].

Precautions

  • Decongestants can exacerbate hypertension.
  • Intranasal decongestants should be limited to 3 days to avoid rebound nasal congestion.

Decongestants can exacerbate hypertension.

Intranasal decongestants should be limited to 3 days to avoid rebound nasal congestion.

  • Nasal irrigation with saline, pseudoephedrine, most antihistamines, and some nasal steroids are safe during pregnancy and lactation.
  • Antibiotics safe in pregnancy and lactationAmoxicillin, amoxicillin-clavulanate, cephalosporins
  • Antibiotic contraindicated: doxycycline, fluoroquinolones
  • Antibiotic safe in lactation but not pregnancy: levofloxacin

Nasal irrigation with saline, pseudoephedrine, most antihistamines, and some nasal steroids are safe during pregnancy and lactation.

Antibiotics safe in pregnancy and lactation

  • Amoxicillin, amoxicillin-clavulanate, cephalosporins

Amoxicillin, amoxicillin-clavulanate, cephalosporins

Antibiotic contraindicated: doxycycline, fluoroquinolones

Antibiotic safe in lactation but not pregnancy: levofloxacin

SURGERY/OTHER PROCEDURES

  • If medical therapy fails, consider sinus irrigation.
  • Functional endoscopic sinus surgery is the preferred treatment for medically recalcitrant cases.
  • Absolute surgical indicationsMassive nasal polyposisAcute complications: subperiosteal or orbital abscess, frontal soft tissue spread of infectionMucocele or mucopyoceleInvasive or allergic fungal sinusitisSuspected obstructing tumorCSF rhinorrhea
  • Massive nasal polyposis
  • Acute complications: subperiosteal or orbital abscess, frontal soft tissue spread of infection
  • Mucocele or mucopyocele
  • Invasive or allergic fungal sinusitis
  • Suspected obstructing tumor
  • CSF rhinorrhea

INPATIENT CONSIDERATIONS

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

PATIENT EDUCATION

  • http://familydoctor.org/familydoctor/en.html
  • https://www.nlm.nih.gov/medlineplus/

PROGNOSIS

COMPLICATIONS

  • Serious complications are rare.
  • Meningitis, orbital cellulitis, brain abscess
  • Cavernous sinus thrombosis
  • Osteomyelitis, subdural empyema

REFERENCES

ADDITIONAL READING

  • Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam Physician. 2011;83(9):1057-1063.
  • Centers for Disease Control and Prevention. Get Smart: homepage. http://www.cdc.gov/getsmart/.
  • Williams JWJr, Aguilar C, Cornell J, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2003;(2):CD000243.
  • Wilson JF. In the clinic. Acute sinusitis. Annal Intern Med. 2010;153(5):ITC3-1-ITC3-15.

CODES

ICD10

  • J01.90 Acute sinusitis, unspecified
  • J01.00 Acute maxillary sinusitis, unspecified
  • J01.20 Acute ethmoidal sinusitis, unspecified
  • J32.9 Chronic sinusitis, unspecified
  • J32.8 Other chronic sinusitis
  • J32.4 Chronic pansinusitis
  • J32.3 Chronic sphenoidal sinusitis
  • J32.2 Chronic ethmoidal sinusitis
  • J32.1 Chronic frontal sinusitis
  • J32.0 Chronic maxillary sinusitis
  • J01.91 Acute recurrent sinusitis, unspecified
  • J01.81 Other acute recurrent sinusitis
  • J01.80 Other acute sinusitis
  • J01.41 Acute recurrent pansinusitis
  • J01.40 Acute pansinusitis, unspecified
  • J01.31 Acute recurrent sphenoidal sinusitis
  • J01.30 Acute sphenoidal sinusitis, unspecified
  • J01.21 Acute recurrent ethmoidal sinusitis
  • J01.10 Acute frontal sinusitis, unspecified
  • J01.01 Acute recurrent maxillary sinusitis
  • J01.11 Acute recurrent frontal sinusitis

ICD9

  • 473.9 Unspecified sinusitis (chronic)
  • 461.9 Acute sinusitis, unspecified
  • 461.0 Acute maxillary sinusitis
  • 461.2 Acute ethmoidal sinusitis
  • 461.8 Other acute sinusitis
  • 473.0 Chronic maxillary sinusitis
  • 473.1 Chronic frontal sinusitis
  • 473.2 Chronic ethmoidal sinusitis
  • 473.3 Chronic sphenoidal sinusitis
  • 473.8 Other chronic sinusitis
  • 461.3 Acute sphenoidal sinusitis

SNOMED

  • 36971009 Sinusitis (disorder)
  • 15805002 Acute sinusitis (disorder)
  • 68272006 Acute maxillary sinusitis (disorder)
  • 67832005 Acute ethmoidal sinusitis
  • 73237007 Chronic ethmoidal sinusitis
  • 40055000 Chronic sinusitis (disorder)
  • 38961000 Chronic sphenoidal sinusitis
  • 35923002 Chronic maxillary sinusitis
  • 77919000 Acute sphenoidal sinusitis
  • 60130002 Chronic frontal sinusitis

CLINICAL PEARLS

  • When bacterial infection is present, patients recover somewhat more quickly with antibiotics, but the majority will recover with symptomatic treatment alone, and accurate diagnosis of bacterial sinusitis is very difficult.
  • Multiple meta-analyses have demonstrated no benefit of newer antibiotics over amoxicillin or doxycycline.
  • Overall NNT to prevent 1 persistent case at follow-up = 15; harm due to antibiotic-associated diarrhea is similar.
  • Significant patient symptom relief with nasal saline spray or drops or irrigation (Neti pot)